Pain treatment and functional improvement in home health care: Relationship with dementia

Using the Outcome and Assessment Information Set to Measure Patient Health Status in Research: A Systematic Review

OBJECTIVES

To review, evaluate, and synthesize existing literature on how health status changes were measured using the Outcome and Assessment Information Set (OASIS).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Studies were included if they examined the health status of adult patients at 2 or more time points using OASIS, which is a comprehensive assessment tool mandated for home health (HH) patients.

METHODS

A systematic search was conducted in PubMed, CINAHL, Embase, and Scopus. The methodological quality of the included studies was appraised using the National Institutes of Health quality assessment tool.

RESULTS

The initial search yielded 1587 citations, resulting in 27 eligible studies published between 2005 and 2022. All included studies were retrospective cohort studies, with overall quality ranging from good to fair. These studies primarily targeted patients with heart failure, with sample sizes between 40 and 6,637,497 and mean ages of 61.2 to 82.4 years. OASIS version C was the most used version, comparing health status at admission and discharge. Patient health status outcomes encompassed functional (n = 24), physiological (n = 6), emotional/behavioral (n = 4), and cognitive (n = 2) outcomes. Various techniques were employed for scale standardization, compositing individual scores, measuring changes, and reporting outcomes. The predominant methods for assessing change included the corrected Likert scale for standardization, composite change scores for change calculation, and continuous outcomes for reporting.

CONCLUSION AND IMPLICATIONS

Researchers have used OASIS to assess patient health status changes in functional, physiological, emotional/behavioral, and cognitive outcomes during the HH episode. Variations in OASIS items and assessment methods across studies have been observed. Our findings underscore the need to standardize item application in research, enabling researchers to synthesize evidence effectively and enhance understanding of patient recovery and HH services. For policymakers and health care providers, these insights could inform resource allocation, care planning, and tailored interventions, ultimately improving health care quality and efficiency.

Longitudinal associations between subjective cognitive impairment, pain and depressive symptoms in home-dwelling older adults: Modelling within-person effects

OBJECTIVES

Cognitive impairment, pain and depressive symptoms are common and interrelated factors in older adults. However, the directionality and specificity of their association remains unclarified. This study explored whether these factors prospectively increase reciprocal risk and examined the longitudinal association between these factors and quality of life (QoL).

METHODS

This study used longitudinal data from The Older Persons and Informal Caregivers Survey Minimal Data Set (TOPICS-MDS; the Netherlands). Older adults self-reported cognitive impairment, pain, depressive symptoms and QoL at baseline and after 6 and 12 months of follow-up. The Random Intercept Cross-Lagged Panel Model was used to assess the prospective association between the three factors, while a multilevel linear regression analysis in a two-level random intercept model was used to examine the longitudinal associations between the three factors and QoL at the within-person level.

RESULTS

The data of 11,582 home-dwelling older adults with or without subjective cognitive impairment were analysed. At the within-person level, pain at 6 months was associated with subsequent depressive symptoms (β = 0.04, p = 0.024). The reverse association from depression to pain, and longitudinal associations between pain and subjective cognitive impairment and between depressive symptoms and subjective cognitive impairment were non-significant. Pain, depressive symptoms and subjective cognitive impairment showed a significant association with poor QoL 6 months later.

CONCLUSIONS

A directional relationship was observed from pain to depressive symptoms. Pain reduction holds a potential benefit in the prevention of depressive symptoms, ultimately optimising the QoL of older adults.

Clinician Perception of Likelihood of Death in the Next Year Is Associated With 1-Year Mortality and Hospice Use Among Older Adults Receiving Home Health Care

Background: Given the complex care needs of older adults receiving home health care (HHC), it is important for HHC clinicians to identify those with limited prognosis who may benefit from a transition to hospice care. Objectives: To assess the association between HHC clinician-identified likelihood of death and (1) 1-year mortality, and (2) hospice use. Methods: Prospective cohort study from the National Health and Aging Trends Study (NHATS) waves 2011-2018, linked to the Outcomes and Assessment Information Set (OASIS) HHC assessment and Medicare data among 915 community-dwelling NHATS respondents. HHC clinician-identified likelihood of death/decline was determined using OASIS item M1034. Multivariable logistic regression was used to assess the association between clinician-identified likelihood of death/decline and 1-year mortality and hospice use. Results: HHC clinicians identified 42% of the sample as at increased risk of decline or death. One year mortality was 22.3% (n = 548), and 15.88% (n = 303) used hospice within 12 months of HHC. HHC clinician-perceived likelihood of death/decline was associated with greater odds of 1-year mortality (odds ratio [OR], 6.57; confidence interval (95% CI), 2.56-16.90) and was associated with greater likelihood of hospice use (OR, 1.61; 95% CI, 1.00-2.62). Conclusion: HHC clinician perception of patients' risk of death or decline is associated with 1-year mortality. A better understanding of HHC patients at high risk for mortality can facilitate improved care planning and identification of homebound older adults who may benefit from hospice.

Association Between Documented Severe Pain and Cognitive Impairment in Home Health Care Patients: Results from the National Outcome and Assessment Information Set Data

Background: Despite the growing importance of home health care (HHC) in the care of older adults with cognitive impairment, limited evidence exists about factors associated with documented severe pain among older adults receiving HHC. Methods: This secondary data analysis used a 5% random national sample of the 2017 national Outcome and Assessment Information Set (OASIS) data. Multivariable Poisson regression model was used to examine the association between documented severe pain, cognitive impairment, and a range of sociodemographic, clinical, and cognitive factors. Results: HHC patients (n = 183,038) were mean age 79.7 years, 61.7% female, and 78.6% non-Hispanic White. In multivariable models, cognitive impairment was associated with lower likelihood of documented severe pain (prevalence ratio [PR] = 0.96, confidence interval [CI] = [0.94-0.98]). Other factors independently associated with less documented severe pain included Hispanic ethnicity (PR = 0.92, CI = [0.89-0.95]), the oldest (≥85 years) groups (PR = 0.65, CI = [0.63-0.66]), male patients (PR = 0.83, CI = [0.82-0.85]), those with a formal diagnosis of Alzheimer's Disease Related Dementias (PR = 0.67, CI = [0.65-0.69]), and patients with verbal- and speech-related difficulty (PR = 0.83, CI = [0.80-0.86]). Patients with history of falls (PR = 1.18, CI = [1.16-1.20]), positive screen on the Patient Health Questionnaire-2 (PR = 1.36, CI = [1.31-1.41]), shortness of breath (PR = 1.14, CI = [1.12-1.14]), anxiety daily (PR = 1.16, CI = [1.14-1.18]), and anxiety daily or more often (PR = 1.40, CI = [1.37-1.43]) were more likely to have documented severe pain. Conclusions: HHC patients with cognitive impairment were less likely to have documented severe pain even with a range of sociodemographic, clinical, functional, and cognitive characteristics were considered. These findings may reflect a link between cognitive impairment missed opportunities for clinicians to provide pain management. Tailored interventions are needed to better assess and manage pain in this vulnerable group of HHC patients.

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

BACKGROUND

Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD.

METHODS

In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses.

RESULTS

The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (β = -0.70, p < 0.001).

CONCLUSIONS

HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.

A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care: A National Analysis

The end-of-life period of individuals with Alzheimer disease and related dementias receiving home health care (HHC) is understudied. We sought to describe characteristics of HHC patients with Alzheimer disease and related dementias at risk of death within a year, based on clinician assessment. We conducted a secondary data analysis of a 5% random sample of the Outcome and Assessment Information Set data set for the year 2017. We used Outcome and Assessment Information Set-C item M1034 to identify HHC patients with overall status of progressive condition leading to death within a year. Multivariable logistic regression model was used to examine the association between sociodemographic, functional, clinical, and caregiving factors and likelihood of decline leading to death within a year, as identified by HHC clinicians. Clinician perception of decline leading to death within a year was higher for Whites (vs Blacks or Hispanics) (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.69-0.80], and OR, 0.63 [95% CI, 0.57-0.69], respectively). Factors associated with increased odds of decline leading to death within a year included daily pain (OR, 1.11 [95% CI, 1.06-1.17]), anxiety daily or more often (OR, 1.58 [95% CI, 1.49-1.67]), shortness of breath (OR, 1.45 [95% CI, 1.34-1.57]), use of oxygen (OR, 1.60 [95% CI, 1.52-1.69]), disruptive behavior (OR, 1.26 [95% CI, 1.20-1.31]), and feeding difficulty (OR, 2.25 [95% CI, 2.09-2.43]). High symptom burden exists among HHC patients with Alzheimer disease and related dementias identified to have a status of decline leading to death within a year.